Provider Demographics
NPI:1922693753
Name:STINE, ETHAN GABRIEL (DC)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:GABRIEL
Last Name:STINE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17330 BEAR VALLEY RD STE 105
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-7741
Mailing Address - Country:US
Mailing Address - Phone:760-245-8182
Mailing Address - Fax:
Practice Address - Street 1:17330 BEAR VALLEY RD STE 105
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-7741
Practice Address - Country:US
Practice Address - Phone:760-245-8182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC34952111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor